Lessons in Orthopaedic Leadership: An AOA Podcast
Lessons in Orthopaedic Leadership: An AOA Podcast
Navigating the Future of Medical Support Staff in a Post-Pandemic World with Thomas L. Miller, MD
The healthcare workforce crisis is reshaping American medicine in profound ways that will impact both providers and patients for decades to come. In this eye-opening conversation, Dr. Thomas L Miller, Chief Medical Officer at the University of Utah, reveals how healthcare institutions are navigating the aftermath of what he calls "a bird's eye view of the future" following the pandemic-induced Great Resignation.
Welcome to the AOA Future in Orthopedic Surgery podcast series. This AOA podcast series will focus on the future in orthopedic surgery and the impact on leaders in our profession. These podcasts will focus on the vast spectrum of change that will occur as the future reveals itself. We will consider changes as they occur in the domains of culture, employment, technology, scope of practice, compensation and other areas. My name is Doug Lundy, host for the podcast series. Joining us today is Dr Tom Miller.
Speaker 2:Dr Miller is the chief medical officer of the University of Utah. He's held that position since 2006, where he's practiced internal medicine since 1993. He's also a professor of medicine in the Division of Internal Medicine of the Department of Medicine at the University of Utah. Dr Miller received his MD from George Washington University in 1988, completed his residency in internal medicine at the University of Utah in 1991, and he's been a member of the Division of General Medicine since 1992. He's board certified in internal medicine. His clinical expertise is in adult medicine, including evaluation and treatment of hypertension, lipid abnormalities, adult onset diabetes and heart and vascular disease.
Speaker 2:And if y'all are thinking that Dr Miller's name is familiar, he joined us at the AOA annual meeting in Salt Lake on the 15th of June in 2023 in our first symposium, where we discussed the changing environment and dynamics of healthcare, which included private equity and supply chain, and the changes in support staff workforce which Dr Miller spoke to, and then this was subsequently published in the Journal of Bone and Joint Surgery in 2024. So Dr Miller is well-versed to the AOA and the activities that we're doing here. So, dr Miller, welcome to the podcast, sir.
Speaker 3:Thanks, Dr Lundy. It's a pleasure to be here and an honor. Thank you for having me on the show.
Speaker 2:Yes, sir, my pleasure. All right, tom. So you, as chief medical officer at the University of Utah and we discussed this when we were in Salt Lake, when the AOA was there about the changes in support staff workforce you saw this firsthand with the COVID pandemic and then all the great quote-unquote, great resignation and everything that happened after that. So, sir, tell us from your viewpoint, from your vantage, where do you see the future going, not just in orthopedic surgery but in all the House of Medicine, in terms of the change in support staff workforce?
Speaker 3:Yeah, let's talk about nursing and all the allied healthcare positions. Initially, since the pandemic, we've had a leveling, so to speak, of our ability to hire nurses. They've come back.
Speaker 3:We no longer have travelers, so we've had some improvement in that, in that I think we're at about a 4% turnover rate now, which is much better than it was during the great resignation. Where we're still working hard to hire and retain would be at the levels of the CRNAs, the registered assistants, medical assistants and others at entry-level positions throughout the university and I believe this is also true throughout the country. These types of positions are heavily in demand, not necessarily for that particular skill, but at that pay scale throughout the economy, so they can work at Costco or they can work for Amazon, they could be drivers, they could do all kinds of different things for the entry level fee. So we've seen an increase in our ability to hire and retain medical assistants and CRNAs. But this is the group that we're really focused on and is toughest right now to retain.
Speaker 3:And I think, Doug, I'd add that, as everybody knows, the cost of the individuals now is rising in the sense of their wages. We've seen nationally over the last couple of years about a 10% increase in the salaries and wages I should say wages of these employees, and so 60% of most healthcare systems expenses actually labor, so it's the lion's share of the expense, and so this is something that is necessary if we're going to retain adequate work staff, but also a problem for us. Wow, Right now we're doing okay. I mean we're we're. We're doing a lot better than we were, you know, when I presented in Salt Lake a year or more ago.
Speaker 2:Okay, 60%, that's crazy.
Speaker 3:Yeah, that statistic comes from the AHA and their recent publication about how healthcare systems are doing across the country. I think let's see I've got here. Labor amounted to something like $839 billion of health systems cost and that's 60% of their total cost. You know you have 8% related to drugs as an example. I mean, we all talk about the rising cost of drugs, the difficulty, but the real expenses in personnel and labor.
Speaker 2:So that's crazy. Well, we all we're all very familiar with the fact that many believe that the healthcare system is already too bloated, that the cost of healthcare in the United States is exceedingly too high. Nobody wants to put more money into it. And if that's the case, where are we going to get these additional funds to pay these folks that could get better wages, better employment by driving for Uber or loading trucks for UPS or whatever?
Speaker 3:That's the million dollar question, especially when you need these positions 24-7. It's not like they're working. Eight to five is nine to five, eight to five or whatever it is. As drivers for Amazon, you need round the clock personnel to operate a hospital and a system, and so one of the things that I've been focused on is really, as physicians and this is kind of where I think you know this podcast is helpful is we have to get away from the older culture of paternalism and what I mean by that. We have 50% of physicians are now women or training to be physicians. We need to really embrace our colleagues, be they nurses, medical assistants, crnas, and kind of get out of that old mold of I write the orders and you carry out the orders, and we need to work collaboratively because I think most individuals who enter the healthcare arena in first jobs or as medical assistants or CRNAs.
Speaker 3:They're in those positions for about five years and they turn over because they're entry-level positions, but many times they turn over as RNs or highly trained techs. They go to school during that time and we want to keep them in healthcare and to be able to do that, we have to really embrace them as individuals, as part of a bigger team, and act as if we're playing on a team, rather than having the kind of classic separation that we've had for many, many, many years of where we come into the hospital, we write the orders and everybody else does what he says. We need to be an integral part of the team, even if we're the leaders of that team. We need to have the skills to embrace these people to keep them in place. Team. We need to have the skills to embrace these people to keep them in place.
Speaker 3:You're right, the cost is increasing and unfortunately it's getting to the breaking point, I think, for the common individual out there in trying to afford health care, and we're all reading stories about rural hospitals closing and obstetric units disappearing so that there are delivery deserts around the United States, and I'm sure that may be true as well for orthopedic care in certain areas. So I would say that we must embrace a team model in order to enliven those people who come in to healthcare at the entry-level positions and keep them in healthcare positions and keep them in healthcare.
Speaker 2:So a lot of what you're saying a easy, simpler solution than seeking for funding that doesn't exist is to improve the cultures in our healthcare networks and, even though these folks potentially could do just as well elsewhere, they hopefully develop a sense of meaning and belonging and value for being there. Putting words in your mouth, but that's kind of what I'm saying.
Speaker 3:That's exactly what I'm saying and I think I've seen over many years in practice and in the position I'm in, that sort of sometimes we beat it out of them.
Speaker 2:Yeah.
Speaker 3:You know we're short. We expect them to know more than they do. We have to treat them with respect in relationship to the skills that they have, which are not the same as our skills, but it's essential that they assist us. If they don't, then we're at a real disadvantage and we will have to pay a lot more money in order to get the kinds of people that we want, that have the skills we want. I just don't think they're going to be available.
Speaker 2:Did y'all see this attrition prior to the pandemic?
Speaker 3:No, not as bad. I mean the pandemic was a falling off point, as we're all aware. We continued to have turnover and medical assistance and I mean there's a kind of a war between the systems in Salt Lake to hire these entry level positions through, you know, raising wages, and so we're always going to have that battle. But it wasn't nearly as bad as the pandemic.
Speaker 3:We were doing OK and I'd like to say that we're back to where we were without travelers. We're able to hire, but it's and then with nurses it's kind of at the point where some of the managers are saying, look, I can actually pick and choose now, instead of just taking the first body off the street. And that's not quite true yet for medical assistants or CRNAs, but it's improving slowly.
Speaker 2:So this quote-unquote great resignation, this was all as a result of the pandemic and essentially not necessarily at the beginning but more toward the middle and the end, correct.
Speaker 3:Yes. I think the great resignation, or we should just say the pandemic, gave us a bird's eye view of the future. We are stable and we don't have travelers, but we've seen a big increase in the wage inflation index, labor inflation index. Inflation has impacted the necessity of increasing salaries. Nurses are demanding more, and it's understandable. Salt Lake has become in our part of the world I'm sure it's true in many other places much more expensive to live in as an urban setting, and it's just not the way it was 10 years ago.
Speaker 2:Now, in terms of supply chain y'all, I'm sure y'all are vertically integrated where you have your own nursing school, so you can try to influence those folks in nursing school to work for y'all when they get done right.
Speaker 3:Yeah, that's true. I mean again, you still have the competition with other Sure, and Utah pays lower than many other states for nurses in terms of salaries, and so we do train our own, so to speak. So they're homegrown. We do have, because we have the Wasatch here, we have a lot of young nurses and technicians that come here because of the outdoor recreation. That's a big help, but our salaries and wages are a bit lower than they are on the coast for sure, and so that's been an issue. So I think overall I feel like right now we're stable.
Speaker 3:But I put out that figure again of 60% of healthcare systems. Costs are labor and that's going to continue to increase. It'll mitigate as inflation softens and hopefully that will happen over the next year or two At least that seems to be a little bit of the sign coming out of the feds. But labor is a huge part of what we do and I think a lot of physicians don't realize the magnitude of that expense. And again I go back to how we need to really embrace our colleagues in nursing and all the other allied professions pharmacy, social work and then those MAs that help us in clinic every day. Without them we'd be dead in the wall, absolutely.
Speaker 3:Or techs, I mean, I would say I'm not in the OR as an internist, but that's one of the areas where we did have trouble. We were hiring travelers to keep our ORs up and running and it was very difficult. We were really struggling there for a while. So again, and when those positions are in scarce supply, there's a lot of competition from the non-academic centers around the town that have more dollars to put towards salaries and hire what they need. So academic centers, they're going to have to come up, I think, in the future with a different approach because we can't consistently play the higher wage or salary game in competition with these very large systems.
Speaker 2:Right. So you spoke at the AOA in June of 23, and it was fairly gloomy then, but it's getting better now. When do you think that y'all made the turn to the current what you said 4% turnover rate? It started about six to seven months ago, I think, really around the beginning of the year.
Speaker 3:One thing I'd like to say that I learned from the current what you said 4% turnover rate. It started about six to seven months ago, I think, really around the beginning of the year.
Speaker 3:One thing I'd like to say that I learned from having to prepare for that talk that we actually implemented here is I had read a Harvard Business Review, doug, that said that the biggest concern of your entry-level employees, those who are at the bottom of the wage scale, is not necessarily their salary, but it's their travel time, their commute time. The cost and effort is required to drive from where they live to get to work. And I'd never thought about it. I mean, I maybe thought about it, but I didn't think about it hard, you know, in a way that really got in under my skin until I made that presentation. And guess what?
Speaker 3:After that presentation, I went to our CEO and our counsel and we not only have those individuals driving from their towns that are maybe 30, 40, sometimes longer minutes away from work, but they have to pay to park here. Now, utah is still an automotive transport community. It's not like New York City or Boston. There's subways, buses and all kinds of things there are and we have a great track system. But most people commute to work by automobile and the fact that they commuted and then they had to pay for parking was a non-starter, because all of the other healthcare systems in the valley don't charge for parking, so we started to supplement their salaries to pay for the parking which I got out.
Speaker 3:That was a great takeaway that I actually was able to operationalize from coming to the AOA talk and again this is something that was important to our entry-level employees and what we were finding is they were actually leaving and going to our satellite clinics because we weren't charging for parking there and when your wages are a certain leveling cost is one to two percent of your salary. So we it had been an issue for years and that's because campus you know they campus pays a lot of their costs based on their parking for students, but we're under that umbrella. So we said, all right, let's, let's help those who are traveling a distance to get to work and that's made a big difference. We've had a lot of comments, complimentary comments, about that.
Speaker 2:You know what's kind of funny about that is? We gave a symposium this year at the AOA meeting on resident unions and guess what, One of the big issues at one of the places was parking at one of the places was parking, and there was actually one program that said.
Speaker 2:of course it was multifactorial, far more complicated than this, but one of the main instigators that pushed them into forming a union was the fact that they believed that the system was not accommodating their. That was charging them way too much to park their cars at the hospital, and so they it's funny that a Kimmel. That's also what y'all found as well. If anything comes out of this podcast, I guess we should be looking at what we charge our staff.
Speaker 3:No, I think it's true.
Speaker 3:I mean, I really thought about it and and you know, being a CMO, I mean that that that sort of discussion is usually in the pocket of the COO or the CEO, and we'd had this discussion for a long time. But it became very acute during the great resignation and when, you know, really hit us hard because people were they'd say, well, I'd love the job, but I don't want to pay for parking. And it's a little bit like saying, well, you know, you're working for the mine now and you're going to shop at the company store, so we're going to charge you to park here, right, right for the mine now, and you're going to shop at the company store.
Speaker 3:So we're going to charge you to park here. I mean, it might work in New York where everybody has to pay for parking, but out here they have choices, and so that's something that we did. I credit you having me dig into the articles and the Harvard Business Review talking about entry-level employees really are more concerned about their commute time and the cost of the commute than they are their salary, so that was quite helpful. I did want to switch gears a little bit. You were just talking about residents and I wanted to talk about that a little bit, because it's not only, you know, allied health professionals that we're talking about here in terms of how we go forward to deliver health care in this country, but it's also based on physicians and house staff and APCs. Right, I mean, this is, this is a huge thing and I we can no longer throw residents at the increasing patient love that we have in our facilities. You know the ACGME, rightly, is not going to allow it. Young doctors they're not tolerating right, so fast disappearing. Or residents willing to put up with the eight hour work week and, you know, slave and toil like they did back in the old days. For, you know, at the turn of the 20th century. They want benefits, they don't want to be skimped on. And you know, part of this is, you know, half the workforce now are women and they're having families in the prime of their life, in their 20s, when they want to raise children, and they're just not going to put up with it anymore.
Speaker 3:And so one of the problems I see is that the CMS capped residency slots in 1997. So I mean, we can graduate as many medical students as we want, but they only pay for that many residencies. So your choke point are the number of residencies. Now individual universities and health systems that have residency programs have paid to increase their residency slots, as we have, but that still doesn't meet the demand. So what I see happening nationally is that we we have a much greater population.
Speaker 3:The population grew by what? 23% since 1997. I think we were 273 million in 1997 when they froze the residency slots. We're now up to 335 million individuals in the United States. And so our doctor graduation rate into into practice, into full practice, hasn't increased at the same pace. I can't quote it, but we're not generating enough physicians to to manage the care for the population as it's growing and and so income advanced practice clinicians right Nature hits a vacuum. So here we've seen, just since 2015, we've seen a doubling in the growth of our hiring of advanced practice clinicians we went from 436 to 880. So this is also a cost to the system, right? So this is also a cost to the system, right. And we don't have the physicians to keep up with the growth rate. That I mean, when you think about it, there's not yet a separate college for the training of nurse practitioners. They are trained basically within the College of Nursing.
Speaker 3:But I dare say it's not going to be too much longer before we have we have colleges of physician assistant training and nurse practitioner training that will have their own programs and their own specialties, and this is, in fact, what's rolling out now. We're not graduating physicians at a rate that allows us to take care of the population the same way that we used to, and care is so much more complicated. I mean, think about when you started practicing orthopedics. I'm sure the amount of things that you could do now to assist the patients is much different in scope than you had when you started. It is for me. I mean, the complexity of care is much greater and we need more physicians or more health care providers to do that, and we're not graduating house staff fast enough.
Speaker 2:Wow, yeah, it's been an exponential increase in technology and especially across the field, not just with us, but with everybody. That in and of itself is also indicative of what we're seeing on the support staff side. So it's a total house issue, not just the sports staff as you were saying.
Speaker 3:Yeah, it's kind of. I mean, with the advanced care practitioners it's the Wild West a little bit. Everybody's paying different prices for salaries for their work, they're paying night differentials and currently they can switch Like. I wish I could just kind of jump into orthopedics and do a few hip surgeries.
Speaker 2:It's not that hard. I'm sure you could.
Speaker 3:I think my insurer might have something to say about that. So would the hospital quality board, but they can switch right. So that's kind of interesting. When you think about it is that you can train an APC and orthopedics to do, let's say, sports medicine evaluations, and then they could jump over to neurosurgery because of a night differential in caring for patients in a neurocritical care unit. It's just an example, right, and as medical students are going into residency, they're also because of debt and the availability of higher paying specialties. They're sort of bypassing pediatrics. There's a bit of a crisis in pediatrics in terms of filling pediatric residency slots around the country and there are fewer of them choosing to go into family practice and my beloved specialty of internal medicine.
Speaker 3:They're going on into cardiology and gi if they can, and with that additional training they'll triple their salaries in the meantime. So the nature again who will take care of, who will be the care managers of patients? Primary care it's looking to me more and more like APCs, unless we do something about the fee schedules and that sort of thing. That's on my end of the spectrum. I know that's maybe not part of this conversation, but as we all get older, we need physicians to take care of us, and when we have little kids we need physicians to take care of them and we can't take them to specialists. So it's a problem nationally. So do the apcs fill this role? Do we quick congress to increase the funding for residency slots so we can catch up with population growth?
Speaker 2:different ideas different to your point. This is hitting while the baby boomers are maturing and starting to approach Medicare. Oh yeah, or well, into it. Yeah.
Speaker 3:Yeah, I mean who will take care of them? And then coordination of care also right.
Speaker 3:I mean who will send the orthopedist, the patient, for the right review? Do they send them to a sports medicine doc first, or are they going to send them to an operative orthopedist? Do they know the difference? All of those things are important. I mean, I really like what Charlie Saltzman did here where he developed the soup to nuts orthopedic practice. He's got all under one roof radiology, physical therapy, non-operative physicians, apcs and operative physicians in each of the specialty areas of orthopedic care.
Speaker 2:And to give Charlie credit, as Charlie was the one that got me on to find out about you, to be the speaker at our AOA meeting. So that's our common link is Charlie Salzman, who we all agree is absolutely spectacular a gem of a guy. Let me ask you this, then what innovative things do you see on the horizon, what innovative things that are you're comfortable sharing with us, that y'all are doing to try to get a hold of this incredible change? It looks like, to your point, that on the top of the pyramid if you'll let me go there the advanced practice professionals, whether they be PAs or nurse practitioners, are starting to try to fill that vacuum a bit. But in terms of the support staff as well, is there any innovative, cool things out there that are coming down the pike to help stem that demand?
Speaker 3:Well, this may be not so innovative, but as far as nursing goes we're moving towards magnet recognition and you know people have different views about magnet. I think it's important. I think what nurses are saying is that the work that we do is foundational and we have meaning. The nurses have an ethos, they have professional pride around their work and Magnet puts a ribbon on that, I think. And so I think that organizations should embrace Magnet because it does value the nurses' work and purpose, value the nurse's work and purpose.
Speaker 3:We are in the middle of working towards our magnet designation and I think physicians should embrace that.
Speaker 3:I think, again, this is an example where we can reach out to our colleagues, because theAD designation is basically nursing, saying we're an integral part of caring for patients and we want you to recognize that and be our partners in caring for patients as well. And I think any of us who have worked with inpatients know, or have been inpatients, as I have know, that the nurses are at the bedside way way more than the physicians are, as I have know that the nurses are at the bedside way way more than the physicians are. And there are eyes and ears and we don't always use those eyes and ears in a way that benefits the patient to the highest degree possible. So I don't know that that's necessarily terribly innovative, but I think it is something that is making its way across the country. That's the MAGNET program. So I think we should try to embrace that. The other thing that we talk about but we have not yet done is creating our own schooling for technicians and medical assistants. That's kind of a hard sell.
Speaker 3:You know the university can only do so many things. And do we want to begin a tech school training or do we leave that to some of the local schools? And then do we provide scholarship funding for service, tuition for service? So those are things we have done in the past, but clearly we need to. We need to graduate more radiology technicians or technicians. I wish I had. I wish I had a better innovative answer for you.
Speaker 2:Maybe, maybe parking everybody should focus on yeah, my place here they I'm pretty certain I got this correct is that tuition is free. It's a diploma nurse program. It's not a bsn program, but they can get their bsn after this. But you can get their diploma in nursing and it's completely it's not free. I mean because they work hard to get their degree, but it doesn't cost them anything if they agree to work for the system once they're finished, so they can come out of high school, work or do something else and then come here get their diploma completely free of charge, as long as they work at the system in some way, shape or form, as a nurse. Yeah, I don't think we have that.
Speaker 3:That's great. We don't have that At least I don't think we have that. I believe I would have heard about it. That's a great idea If the system can afford that. That's a fantastic way to bring people in and honor their work and their skills and then keep them for a number of years instead of having too much turnover.
Speaker 2:Do you see a critical point in the future where all of a sudden it becomes apparent that throwing money at the problem doesn't help anymore, that we just don't have enough staff, that care is becoming increasingly problematic, which means that the cost of these folks goes up even more, because as the supply goes down, the demand goes way up, which so goes their wages. And then all of a sudden we have this healthcare crisis across the nation. Is that looming on the horizon?
Speaker 3:Well, I think it's already happening with, as I mentioned at the beginning, the closure of rural hospitals, the deserts of care that are being realized now, and I think the thing that I worry about is that the large systems have the deeper pockets and they have the capital because of their assets to hire at whatever prices the market will bear.
Speaker 3:And that's not only true for allied healthcare professionals, that is absolutely true for physicians. So, as we were talking earlier, when you have an orthopedist or a specialist in high need, those bigger systems can afford much bigger deltas now than they did in the past. So I think what's troubling for some academic centers is this gap between what we used to say well, you're going to join the academic world, you're going to be part of the proud and the great and you're going to work in academic life and you'll make less than you would make in private practice. But that gap is substantially bigger now in terms of what the private nonprofits and for-profits are offering for these positions. And they can afford it. And you know it used to be.
Speaker 3:Well if you were a cardiologist and maybe the academic position was only $50,000 less than what you could make in the community, that's now $200,000, $250,000, in some cases even more if you're highly specialized in some aspect of cardiology like electrophysiology. So I don't know how it is in your world of orthopedics throughout the country, but I suspect there are some similarities to that, and so I think that that is a threat. I think academic centers have to figure out a way. I actually don't know yet. I mean, do we decrease the amount of funding that we put into research? We decrease the amount of funding that we put into research in order to increase salaries to a level that allows us to retain and hire highly qualified physicians, or do we just?
Speaker 3:otherwise I think we run the risk of becoming quite average.
Speaker 2:That's disturbing, I mean have you?
Speaker 3:do you see that in your field at all?
Speaker 2:To a degree, yeah, to a degree, but really more. I think impacting us is the lack of support staff that we all struggle for our medical systems, for the folks to help us get through the day doing all the things we need to do.
Speaker 3:The problem that I just described to you is actually something I've been watching for the last couple of years. That is, the brain drain, if you will, and it's become more acute in the last year and it's now on everybody's mind, to the point that we have a committee looking at salaries position salaries and trying to compare that to the market salaries, physician salaries, and and trying to compare that to the market, because I think things move so quickly that the double amc benchmarks didn't didn't cut it. They were not representative of what was actually going on out there, and I'm talking most about highly paid specialists. So, and it's it's. It's harder too with with primary care physicians. I mean, there's just not enough. So they're even commanding a little bit higher salaries than they had previously.
Speaker 2:Last thing, on digital media or something I saw the other day I can't remember where I saw this that it was in one of the Asian countries. It was, I think, either in Singapore or Japan. If I recall, they actually had robotic nurses, medical assistants, whatever that would help. There are actually robots that would go in and engage with the patient and give them their medications and measure their vital signs and such, and it was just to a certain degree. It was absolutely appalling thinking. Granted, being taken care of by a machine, but of course, as you can imagine, they had this thing humanized as much as possible, with very caring voice and all.
Speaker 3:God help us, my friend, if we end up in that place oh, my wife's already ordered one of those so she can go on vacation. She thinks it's a great idea. Well, there's that oh my gosh, we'll see what happens.
Speaker 3:I, the human touch, is still the most important thing and there's so much joy in medicine and I really want to go back before we conclude and say that I think one of the best ways to avoid burnout and yes, we all have perhaps problems at times to have enough staff, but to work closely and caringly for those that are supporting us and I don't know that brings me joy. I mean, I've had the same medical assistant for almost 20 years and she's fantastic and the patients love her and we all get cranky from time to time, but it's a team and it's great and I enjoy the practice and that's why I still have a small practice in comparison to my CMO role. But it makes it all worthwhile and I think as we work together, you know, communicate more with each other about our cases, time pending with that it's good. It improves the joy of medicine. That's why we got into it. At least I did.
Speaker 3:It helps.
Speaker 2:If I could summarize the three things in here one is work on the culture in our clinics, taking care of the folks that take care of us. Number two search for innovative ways to try to address this incoming and inevitable crisis that's coming down the pike. Number three make sure that we're not charging too much for parking.
Speaker 3:Yeah, yeah, car in every garage and chicken. And two cars in every garage and a chicken in the pot. So there you go.
Speaker 2:It's been my pleasure discussing workforce issues and the future in workforce with Dr Tom Miller, who's the chief medical officer at the University of Utah. Dr Miller is obviously an expert in these things and we did enjoy having him at the AOA meeting and once again on this podcast. So, Dr Miller, sir, thank you for joining us there. My pleasure. It was great talking with you. Yes, sir, and y'all look forward to futures in orthopedic. On this podcast series.